I just don’t want a C-section, Doc.

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I hear it often in my clinic with the women who are gearing up to have a baby. They just don’t want to have a c section. For some women, it is a feeling that they have failed to have a natural childbirth. For others it is the distrust of modern physicians, and the feelings that doctors perform unnecessary procedures because they are easier. And for some, it is genuinely just the thought of having surgery. I can absolutely relate to all of these concerns. It’s an extremely overwhelming thing, the preparation to have a child. Most of us cope with the fear of the unknown by controlling as many elements as we can, and as any of you mothers out there can attest to, childbirth, and child rearing in fact, rarely goes as planned. As a physician, we rely on two faculties to make clinical decisions: our training and knowledge, and then our instinct. Labor and delivery is one of the few arenas of the hospital where these two aspects are tied so closely together. We have to make difficult calls about both a mother and baby’s health within minutes. Even now after practicing for 9 years, there are moments where I second guess my decision, and regardless of the colleague I speak to, I am told time and time again, “You have to trust your gut.”

joshua-k-jackson-261210I always like to discuss pain control options with expectant mothers. Labor is hard. It’s long and taxing on a woman, both physically and mentally. I always say, it’s important to enjoy the experience, and if you are dropping the F bomb, or yelling at the nurses, or kicking the doctor (It has happened. Luckily they missed, but it was close), you will not be enjoying the experience. Furthermore, a lot of women have natural tearing during childbirth. To repair this, the doctor has to piece together a swollen puzzle. It is already not fun for the new mother to be laying there when everyone else is hovered around this cute new person while she is unable to take her legs out of the stirrups. It is immensely worse when your pain is out of control, if the local anesthetic is not cutting it. (Sidebar, the vagina is an extremely forgiving area and you will look beautiful again, just don’t use a hand mirror for 6-8 weeks.) An epidural can make the put-back-together process way easier for the patient AND the doctor. Here’s my disclaimer on epidurals: They are a process. The patient has to be admitted, in some cases have baseline labs drawn and resulted, get a bolus of fluids through their IV, and then they have to be assessed by the anesthesiologist to make sure they can sit still long enough to have the epidural placed. I have had patients who walk into labor and delivery in pain, who expect to have the thing in their back within 5 minutes of getting there. This is a medical procedure too. It takes some time and there are steps preceding it.

So what happens if you don’t get an epidural? Some women don’t want one or, in some cases can’t have an epidural. As a physician caring for ladies without an epidural, I do realize that it is your choice and just want you to be aware of the pros and cons, so you can make an informed decision about pain control. You should know that if an emergency occurs during your labor that results in the need to quickly deliver your baby, without an epidural, this delivery would have to happen under general anesthesia which is much riskier. To be fair, epidurals themselves have risks too and most women do not need emergent deliveries who are epidural-free. It is a risk that should be understood, however, before the first contraction hits. Also keep in mind that NO epidural does not automatically mean you will have a vaginal delivery, nor does an epidural equal a c-section. Roughly one third of all deliveries are via c-section. Epidurals placed in active labor do not increase a woman’s chance of having a c-section, according to multiple studies. Again, everything has risks.

Something that is always devastating to discuss is maternal and neonatal morbidity- meaning the chance of mother or baby being harmed during childbirth. My patient matt-palmer-171734.jpgpopulation tends to be very healthy and low-risk. Having a baby is a joyful occasion, and because of this, we tend to overlook the tremendous risk and danger that can come from having a child. As I continue to practice, my reverence to pregnancy and my realization as to just what a miracle it is that any of us made it out of the womb alive, with all our faculties, limbs and organs working, continues to grow. In developing countries, it is a given that children die during and after childbirth, just as it is a given that mothers often do as well. In the United States, though,  bad outcomes are unacceptable. Despite this incredible focus on creating good outcomes, maternal morbidity has continued to rise in this country for a variety of reasons. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html. I always stress to any woman who is contemplating childbirth to stop smoking, start exercising, lose weight if they need to, and get a general check-up to ensure there are no underlying issues that can worsen during pregnancy.

When people say to me, “I just really don’t want a cesarean section”, I tell them all the same thing: The only way to avoid a c-section is to not get pregnant. Childbirth is a wonderful and beautiful miracle. It is also not something anyone should take for granted. Ask your doctor questions, research the things they are telling you (not on Google chat groups), make sure you are keeping an open dialogue with them during your nearly 10 months of prenatal care so that you trust their judgment and their gut instinct during the unpredictable but amazing labor and delivery process. If something doesn’t seem right, speak up. If your baby isn’t moving enough to satisfy your kick counts in the third trimester, call the doctor that day. If your doctor says you need surgery to prevent irreparable damage to you or your unborn child, please trust them. Having to do a cesarean section, but walking away with a healthy mother and baby is 100% of the time a win for me as an obstetrician.  And my final thought… get an epidural 😉

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